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Further to my recent letter explaining how the full political context of the Freemantle study was not adequately declared(1), several other interesting pieces of information have come to light which I feel should be made available to the BMJ’s readers.

An email sent on the 3rd February 2015 by a Deloitte employee to officials at NHS England including Bruce Keogh reveals the intricate involvement of both Deloitte and Simon Stevens (Figure 1). The main questions arising from this meeting involving Stevens, Keogh and Deloitte included ‘What is the clinical case for seven day services, especially re mortality?’ and the resulting action was documented as ‘Bruce agreed to have the mortality analysis from 2008 updated’. It is interesting that the involvement of both Simon Stevens and Deloitte in the study’s inception was not documented anywhere in the Freemantle study(2).

It is also salient that another question arising from this meeting was documented as ‘what is needed from pay negotiations to improve affordability?’ which demonstrates a clear link between the 7 day reforms and doctors’ contracts. The email also stated another action as ‘Deloitte to run mortality bundle to show services needed to address mortality variation’. This implies that those involved, including Bruce Keogh and Simon Stevens, had already made the assumption behind closed doors that the mortality variation was ‘addressable’, despite the fact that it appears to contradict the gist of the authors’ clear statement that to assume this mortality variation was avoidable was both ‘rash and misleading’. A further email sent by Simon Bennet of NHS England to Deloitte on the 11th January 2016 states ‘Whilst I believe we shared with you high level mortality risk figures from a re-analysis of 2013/4 admission to help with your modelling…’ (Figure 2). Data presented to NHS England in 2014 confirms the recurrent theme of recent media stories regarding the government’s 7 day reforms, with it being stated that ‘the workforce costs need to be addressed’(3) (Figure 3).

In the context of recent media stories detailing the ‘airbrushing’ of the Freemantle study by the Department of Health(4), the incomplete manner in which the context and inception of the Freemantle study has been presented to readers has significant implications as to its overall meaning. The bottom line remains that doctors and patients want 7 day reforms, but only if the government is willing to adequately fund this service expansion so that it is properly and safely staffed; Chris Hopson, the CEO of NHS Providers, has recently spoken out about the ‘chasm’ which exists between the government’s promised delivery and current levels of funding(5). Given that widespread staffing problems that already exist, the government’s attempt to expand services by bullying poorer terms and conditions on staff appears misguided, counterproductive and dangerous.

In my view, the recent correction (1) still fails adequately to comply with the editorial standards set out in the ICMJE’s competing interests declaration form, as used by the BMJ, which asks (2):

“Are there other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work?”

The correction merely reiterates that Bruce Keogh, medical director of NHS England, is a proponent of 7 day services. It ignores the wider political context to the commissioning of this paper and, in particular, the following admissions in an NHS England press release to the BBC on 23rd February 2016 which stated:

“In December 2013, a paper based on the 2012 findings and work of the Seven Days a Week Forum (SDaWF) was presented to the NHS England board. The recommendations set out in paper were accepted and agreed. At the same time, NHS England commissioned Deloitte to analyse how the system might be affected.

……In November 2014, Deloitte were invited to a meeting of the NHS England Medical Directorate Senior Management Team (SMT) to update on progress. The same update was then presented to the senior leadership of NHS England in February 2015, where further information and analysis was requested.

Consequently, on 5 February 2015, University Hospital Birmingham was asked by NHS England to re-run the analysis used in the 2012 paper on 2013/14 data to assess if there was still a weekend effect.”

In my opinion it is clear that as things stand that the full political context of the study has not been adequately declared to both readers and the general public. It may indeed be technically true that BK did end up asking for the analysis; however the background to this request was not fully and transparently declared. Given that the request from Keogh came off the back of Deloitte’s background work and a meeting involving the senior leadership of NHS England, at the very least the involvement of the senior leadership of NHS England should have been declared as a competing interest.

NHS England has invested significant effort on seven day services since setting up the ‘Seven Days a Week Forum’ in February 2013. It published a December 2013 paper recommending consultant contract changes to ensure they worked seven days a week (3). This effort is still ongoing, with well-publicised proposed changes to consultant contracts that have yet to be finalised, and consultant review within 14 hours is now a ‘priority clinical standard’. This background information is important; it may or may not have contributed to the claim in the first draft of the article that some of the prolonged weekend effect may be the ‘access to senior specialist care are reduced from late Friday through the weekend’ (4). Peer reviewers were denied the opportunity to consider this possible conflict of interest and potential source of bias. The claim was removed regardless, as one of the reviewers suggested other causes may contribute to the weekend effect.

This evidence, which has emerged only since the publication of the Freemantle study, has shown that the study was effectively commissioned by NHS England as part of their extensive body of work on 7 day reforms, following on from this previous unpublished and possibly never-to-be-published work by Deloitte. At a minimum the BMJ have a duty to their readers and the public to ensure that the article is corrected to reflect the full and true political context of the study.